101 results
76y · Male·out-of-hospital cardiac arrest in a man with coronary artery atherosclerosis and…
Graham John Butler, aged 76, died from out-of-hospital cardiac arrest secondary to coronary artery atherosclerosis and diabetes whilst imprisoned at Acacia Prison. He had significant cardiac history including prior myoca…
55y · Male·decompensated liver failure in a man with metastatic hepatocellular carcinoma, w…
Tony Ruich, a 55-year-old sentenced prisoner, died from decompensated liver failure due to metastatic hepatocellular carcinoma with terminal palliative care. He had pre-existing cirrhosis diagnosed in 2012, likely from h…
64y · Male·complications in association with thermal injuries in a man with underlying chro…
Kim Vulich, a 64-year-old man with decompensated liver cirrhosis from chronic alcohol use, developed hepatic encephalopathy and cognitive impairment including possible Korsakoff syndrome. Despite SAT guardianship orders …
32y · Male·ligature compression of the neck (hanging) in a man with methadone and methylamp…
Kingsley Garlett, aged 32, died by hanging in a maximum security prison cell on 31 July 2022. The evidence indicates his death was an impulsive response to relationship conflict with his partner revealed through prison p…
31y · Female·organ failure due to anorexia nervosa
Chloe Tupper died of organ failure due to severe anorexia nervosa at age 31. She had suffered from this illness for 17 years since age 14, receiving multiple episodes of hospital-based refeeding that never achieved lasti…
89y · Male·Complications in association with a gastrointestinal illness in an elderly man w…
Raymond Sydney Cheek, an 89-year-old prisoner with multiple comorbidities including insulin-dependent diabetes, died from complications of gastrointestinal illness with acute renal failure. While medical care at Casuarin…
48y · Male·metastatic high-grade neuroendocrine carcinoma, treated palliatively
Lindsay Woods, a 48-year-old Aboriginal man with chronic paranoid schizophrenia, organic psychosis, and ischaemic heart disease, died from metastatic high-grade neuroendocrine carcinoma. He was subject to a custody order…
76y · Male·metastatic prostate cancer with terminal palliative care
Kevin John Keath, aged 76, died from metastatic prostate cancer while serving a life sentence at Casuarina Prison. He received holistic, compassionate, and appropriate healthcare throughout his incarceration, including r…
27y · Male·unascertained
Neil Lindsay Kobelt, a 27-year-old man with diagnosed schizophrenia, disappeared from Kalgoorlie, Western Australia in February 1982, shortly after discharge from hospital for acute psychiatric crisis. He had relocated t…
52y · Male·end-stage throat cancer
Lincoln Campbell, a 52-year-old Aboriginal man with terminal throat cancer, disappeared from Kununurra Hospital on 24 December 2005 while receiving palliative care. He had a PEG feeding tube, required regular morphine an…
46y · Male·Aspiration pneumonia in an obese man with a history of diabetes mellitus, obstru…
Samuel Edward Ashby, a 46-year-old prisoner with treatment-resistant schizophrenia, died from aspiration pneumonia complicated by clozapine effect. Key clinical lessons: (1) smoking cessation dramatically increases cloza…
66y · Male·Cardiac arrhythmia in a man with arteriosclerotic cardiovascular disease, pulmon…
Bradley Stinson, a 66-year-old prisoner with a long history of heavy smoking and alcohol use, died from cardiac arrhythmia in the setting of arteriosclerotic cardiovascular disease, pulmonary thromboembolism, and metasta…
83y · Male·complications of ruptured abdominal aortic aneurysm (treated surgically)
An 83-year-old male prisoner died from complications of a ruptured abdominal aortic aneurysm (AAA) after a 5-month delay in diagnostic confirmation and treatment. An incidental finding of an 8.7 cm AAA was identified on …
75y · Male·acute bronchopneumonia in a man with comorbidities
A 75-year-old sentenced prisoner died from acute bronchopneumonia with comorbidities. Mr Rice had extensive medical complexity including COPD, cardiac disease, peripheral vascular disease, and diabetes. He was appropriat…
41y · Male·haemothorax due to ruptured thoracic aortic aneurysm in a man with Marfan syndro…
A 41-year-old man with Marfan syndrome and a thoracic aortic aneurysm managed conservatively with blood pressure medications died from aneurysm rupture while imprisoned. Methylamphetamine in his system significantly elev…
75y · Female·Complications including acute pancreatitis and refractory intra-abdominal sepsis…
Lee Milcherdy, 75, died from complications including acute pancreatitis and refractory intra-abdominal sepsis following an unnecessary ERCP procedure. An MRCP scan on 12 October 2018 showed no gallstone, making the plann…
54y · Female·unascertained
Carole Livesey, a 54-year-old woman with severe anorexia nervosa and major depression, absconded from Rockingham Hospital psychiatric unit on 3 October 2017 during an escorted walk in hospital grounds. She had been an in…
Male·Complications of alcohol and hepatitis C-related liver disease
Peter Young, an Aboriginal man with advanced alcoholic cirrhosis and recently acquired hepatitis C infection, died of multi-organ failure while on remand in custody. He received appropriate standard medical care in priso…
63y · Male·respiratory failure in a man with lung cancer, chronic obstructive pulmonary dis…
Stephen Craig Solly, aged 63, died from respiratory failure due to advanced lung cancer, COPD, and pulmonary fibrosis while an involuntary psychiatric patient at Graylands Hospital. He had paranoid schizophrenia, cogniti…
57y · Male·atherosclerotic heart disease in a man with diabetes mellitus
Macker Joseph Dinah, a 57-year-old Aboriginal man, died suddenly in his prison cell from atherosclerotic heart disease complicated by diabetes mellitus. He had severe coronary artery disease affecting three vessels, prev…
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